Study finds racial disparities in advanced HF therapies

A new study shows that black Americans received ventricular assist devices (VADs) and heart transplants about half as often as white adults, even when receiving care in an advanced facility. heart failure (HF) center.

The analysis, drawn from 377 patients treated at one of 21 VAD centers in the United States under the RIVIVAL studyfound that 22.3% of white adults had received a heart transplant or VAD, compared to 11% of black adults.

“That’s what we’re so concerned about, that we’re seeing this pattern in this selected population. I think it would be too reasonable to speculate that it could very well be worse in the general population,” he said. said study author Thomas Cascino, MD, MSc, University of Michigan, Ann Arbor, commented lecoeur.org | Medscape Cardiology.

The study was published online in Circulation: heart failure and relies on previous work by the researchers showing that patient preference for early VAD treatment is associated with higher New York Heart Association (NYHA) class and lower income level, but not race.

In the present analysis, the number of black and white participants who said they “definitely or probably” wanted VAD therapy was similar (27% vs. 29%), as was the number of people wanting “all life-saving therapies” (74% versus 65%).

Two-thirds of the cohort were NYHA Class III, the mean EuroQoL Visual Analogue Scale (EQ-VAS) score was 64.6 among the 100 participants who identified as black and 62.1 among the 277 white participants, and the average age was 58 and 61 years old. , respectively.

Mortality rates were also similar during the 2-year follow-up: 18% of black patients and 13% of white patients.

After controlling for several clinical and social determinants of health, including age, INTERMACS (Interagency Registry for Mechanically Assisted Circulator Support) patient profile, EQ-VAS score, and education level, black participants had a 55% lower VAD or graft compared to white participants (relative risk, 0.45; 95% confidence interval, 0.23, 0.85). Adding the VAD preference to the model did not affect the association.

“Our study suggests that we as providers may make decisions differently,” Cascino said. “We can’t say for sure what the reasons are, but structural racism, discrimination and provider bias are definitely the things that worry me.”

“It is absolutely necessary that we look within, reflect and recognize that we are probably playing a part in this, and then start to be part of the change,” he added.

“The lives disabled or lost are simply too many”, co-author Wendy Taddei-Peters, PhDa clinical trials project manager at the National Heart, Lung and Blood Institute, said in a NIH Statement. “An immediate step could be to require implicit bias training, especially for transplant and VAD team members.”

Other suggestions are better follow-up of underserved patients and the reasons why they do not receive VAD or are not registered for a transplant; the inclusion of psychosocial components in decision-making regarding the application for advanced therapy; and bringing “disparity experts” into cardiac team meetings to help identify biases in real time.

Commenting on the study, Khadijah Breathett, MD, HF/transplantation cardiologist and tenured associate professor of medicine, Indiana University Bloomington, said, “I’m glad there’s more push for awareness because there’s still has a population of people who don’t believe this is a real problem.”

Breathett, who is also a racial equity researcher, noted that the findings are similar to several studies suggesting racial disparities in HF care. In its own study 2019 of 400 providers showed identical clinical vignettes except for race, survey results and aloud interviews showed that decisions about advanced HF therapies are hierarchical and undemocratic, antecedents social and adherence are the most influential factors, and black men are seen as untrustworthy and adherent, despite having identical social backgrounds, which ultimately led to white men being offered transplant and VAD implantation for men black. The bias was particularly evident among older claimants.

“This problem is real,” Breathett said. “The process for awarding lifesaving therapies is not fair and there is some level of discrimination against people of color, especially black patients. It’s time we thought about how we address these issues.”

To see if centers can move the needle and practice system-level changes, Breathett and colleagues are launching the search for objectivity in the attribution of advanced heart failure (SOCIAL HF) Essay on therapies at 14 sites in the United States. It will measure the number of minority and female patients receiving advanced HF therapies at randomized centers to receive usual care or HF training, including evidence-based bias reduction training, use objective measures of social support and changes to facilitate group dynamics. The trial is scheduled to begin in January and end in September 2026.

“The main takeaway from this study is that it highlights and re-emphasizes the fact that racial disparities exist in access to advanced therapy care,” said Jaimin Trivedi, MD, MPH, associate professor of cardiothoracic surgery and director of clinical research and bioinformatics, University of Louisville, Kentucky, said in an interview.

He also called for education and training for all professionals, not just during residency or fellowship, to specifically identify issues with black patients and encourage black patients and family members to get involved. more in their HF care.

Trivedi said further studies should examine why mortality rates were similar in the study despite the disparities seen in VAD implantation and transplantation.

He also pointed out that while the study patients were treated from July 2015 to June 2016, a recent analysis by his team from the United Network for Organ Sharing (UNOS) database showed that 26% of transplants in 2019 were to black patients, up from just 5% in 1987. “So there are some encouraging signs as well.”

Cardiac failure Circ. Published online October 19, 2022. Summary.

The study was funded by the National Institutes of Health/National Heart, Lung, and Blood Institute (NHLBI) and the National Center for Advancing Translational Sciences. Cascino declares that it has no relevant financial relationship. Four co-authors report financial connections, including David Lanfear, who serves on Medscape’s advisory board. Breathett reported funding from multiple NHLBI grants.

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